Sunday, November 13, 2016

A 30 year old with persistent vomiting and epigastric pain over 1 week (presented by 3rd semester MBBS Ravi Jain, Souptik Biswas and Avinash Kumar)


This is a HIPAA de-identified open-online-patient-record shared here by Ravi Jain, Souptik Biswas and Avinash Kumar, 3rd Semester, MBBS, WBUHS, West Bengal and UCMS, Nepal  autumn 2016 after collecting informed patient consent 
(forms downloadable here: ) 

The students have tried to present it in the SOAP format (as detailed here:

A 30 years old woman

presented with

the complaints of:

Subjective -

Persistent Vomiting - greenish yellow colored. 8-9 times
Heart Burn
Pain abdomen, in epigastric region,
Sleep improper
Didn’t pass stool for 5-6 days

She was suffering from pain in the stomach since 8-9 days before admission

Objective -

General examination and abdominal examination: (to be filled up by Ravi Jain and Souptik using this link:


WBC count increased (11,700)
Hb Normal
MCH decreased (26.😎
S. creatine decreased (0.6)
A:G decreased (1.1)

Initial clinical assessment of the student -
Stomach tumor
Acute Pancreatitis

Student queries on reflection (More about the learning and assessment methodology here :

Q. - 1. Why heart burn?
Q. - 2. Why she didn’t pass stool for 5-6 days?

Later more objective findings below:

Most of our students don't type. They still use handwritten notes as below (original note that was typed by another student elsewhere):

Conversational clinical decision support:


Rakesh Biswas Boudhayan can we add Dr Nidhi Jain for her comments regarding the patient's CECT here:
Boudhayan Dm Dr. Nidhi Sehgal Maam could we have ur inputs here regarding the findings in the CT Scan as requested by Rakesh BiswasSir
Nidhi Sehgal Only one image is there
Nidhi Sehgal Please post some more
Boudhayan Dm Nidhi Sehgal Maam rest in ur console room....I guess we can all access it only tomorrow
Nidhi Sehgal This don't look no gastric distension...have to see other images..
Rakesh Biswas
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Rakesh Biswas I guess we can't ask our pathologists to comment on just one low power image here: but will be good to learn what they report on her biopsy tomorrow after going through all her slides. AadiptaSumedha hope you are able to follow it up.
Boudhayan Dm Dr. Debdatta Basu Sir could we kindly have your inputs on the available slide picture
Debdatta Basu Just one slide and that too at a low power magnification is not enough to come up with a diagnosis. Pathologists are not magicians...😊
Rakesh Biswas
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Rakesh Biswas Souptik thanks for the microscopic image. Please follow up on what the evaluation of this and all other images by our pathologists brings tomorrow.
Avinash Kumar Gastric outlet obstruction causing heart burn and green yellow vomit due to acid.
Rakesh Biswas
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Rakesh Biswas Why not the other DD as mentioned by Ravi? 
Avinash Kumar Persistent vomiting 8-9 times, because of obstruction. And so not pancreatitis but may be tumor
Rakesh Biswas
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Boudhayan Dm With the Histopath Pic request My teacher and my Guardian in JIPMER Dr. Debdatta Basu to kindly help the UG students as they explore and experience patient based learning
Nidhi Sehgal I have seen this case on console...gastric wall thickening is pyloantric region
Rakesh Biswas Thanks Dr Nidhi What do you think it will turn out on biopsy? Ulcer of cancer? 
Nidhi Sehgal Circumferential thinking is there...likely neoplastic... But with preserved fat plane....still difficult to say..
Nidhi Sehgal Is biopsy done?...if yes...let me know the result sir
Rakesh Biswas Should have gotten it today Boudhayan?
Nidhi Sehgal D/D...Idiopathic hypertrophic pyloric stenosis
Rakesh Biswas The slides are ready and waiting in Patho.
Rakesh Biswas Boudhayan can you add one of our faculty from Pathology here?
Rakesh Biswas Souptik any news of the slide today? How was your community medicine PCT (for which you were absent in medicine ward today)? 
Boudhayan Dm Will inform as soon as I come to know
Boudhayan Dm Sir initially I thought of PCT as Procalcitonin or Paracetamol
Boudhayan Dm Sir PCT is also important but it is essential to learn time management......So a probable solution is that you can start PCT in Medicine in its present format and simultaneously incorporate the model as followed in the best Institutions in the world
Rakesh Biswas
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Nidhi Sehgal D/d......IHPS..
Boudhayan Dm Dr. Uttam has the slides ...Can anyone pls add him
Rakesh Biswas BoudhayanSouptik any luck with Dr Uttam?
Rakesh Biswas Boudhayan share the pathology report here. Dr Nidhi it appears benign and this could provide us a fresh perspective on the CECT.
Nidhi Sehgal Benign...but what they mentioned
Rakesh Biswas
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Rakesh Biswas Thanks Dr Nidhi, The histopathology appears to just suggest gastritis. Dr Dipendu you may recall this patient where the endoscopic image suggested malignancy and there was marked gastric outlet obstruction at that time.
Dipendu Mazumder Yes it looked like malignant to me .The lesion was partly ulcerated distally. We can repeat biopsy as sometimes biopsy from superficial tissue may not represent cancer cell .
Rakesh Biswas Thanks Dr Dipendu for these valuable inputs. Raviwe need to have more sections of the biopsy tissue and please share a high power image of the slide here.
Rakesh Biswas Also Dr Dipendu, A follow up endoscopy would help here as if this is really what the biopsy is making us believe at this point the macroscopic findings on endoscopy would significantly resolve. As the patient is asymptomatic now i am hazarding a guess...See More
Dipendu Mazumder Sir we can have a follow up endoscopy in next week to see the status of lesion
Boudhayan Dm Debdatta Basu Sir would invite ur comments in view of these developments and after getting the inputs from Our Gastroenterologist Sir Dr. Dipendu Mazumder
Rakesh Biswas
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Dipendu Mazumder 1st endoscopy picture
Dipendu Mazumder 2nd endoscopy picture
Dipendu Mazumder As you can see compare to previous lesion the size has significantly regressed. Mostly lesion could be small ulcers with perilesional edema and now subsided with therapy. I have repeated biopsy. Lets see ..
Rakesh Biswas Thanks a lot for sharing the follow up endoscopy findings above Dr Dipendu. The lesions definitely appears better than the previous images here: DrNidhi would be good to have your inputs again on the CECT with this hindsight.
Nidhi Sehgal As I mentioned previously... Circumferential thickening was there with well defined fat plane...but was causing marked luminal obstruction... This marked luminal obstruction was going towards neoplastic possibility... But now if the endoscopy is showing reduction of luminal obstruction... This is signifying edema and thus benign cause..can be Gastritis

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